CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.25 9.25 37.00
Subtotal (Total Children Is Unduplicated) 1 0.25 9.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.00 42.48 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 34 35.00 309.05 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 50.00 540.00 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 4.00 33.76 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 47 49.00 1067.71 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.00 226.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 21 22.00 699.82 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 17.00 1275.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 12.50 693.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 67.50 5062.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 25.50 1912.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 160.50 8907.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 31.00 2325.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 14.00 679.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 27 27.00 1309.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.00 582.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.00 1067.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 63.00 3055.50 48.50
Subtotal (Total Children Is Unduplicated) 268 649.00 31601.70 48.69
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 6.25 312.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 56 66.50 3325.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 5.00 125.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 33 29.00 1450.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 6.25 312.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 74 87.50 4375.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.50 62.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 22 274.75 13737.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 218 1920.50 96025.00 50.00
INTR-INTR-INTERPRETER 11 126.25 6312.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 184 1172.25 79571.81 67.88
OCCT-97530HM-OT SESSION BY OT ASST 35 310.00 16839.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 121 706.00 47935.44 67.90
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 301 1939.75 132230.24 68.17
TRAN-TRAN-FAMILY TRANSPORTATION 2 210.00 178.50 0.85
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 618 161704 137477.26 0.85
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 764 168609 542316.39 3.22
----------------------------------------------------------------------------------------------------------------
Total 169257.75 573927.34 3.39
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 789
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.25 9.25 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3320 160605.54 360443.86 360443.86
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1527 8651.96 213474.23 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4848 169257.75 573927.34 360443.86